The Future of HIV Prevention, Treatment and Care

TheBodyPRO.com recently interviewed longtime activist Mark Harrington, the executive director of Treatment Action Group. Harrington talks about the ramifications of the PARTNER study results, as well as what to expect from HIV treatment and care in the next five years.

How is HIV prevention changing today?

One of the really interesting things about the renewed discussion and debate about prevention in the gay community is that a lot of people are explicitly beginning to say one of the goals of ending the epidemic is to be able to have condomless sex without being worried about HIV transmission. And there are some people who can do that today, right? If you're in a seroconcordant relationship and you both got tested yesterday, and you've been totally faithful since then, you probably could have sex without a condom today. And if you're in a serodiscordant relationship and one person's got an undetectable viral load, or their partner's on PrEP [pre-exposure prophylaxis], or both, you can probably have condomless sex without risk of transmission.

Even from the PARTNER study recently -- even just one partner being virally suppressed, and the other being negative, it seems like the rate of transmission was low, was very low, in the first two years of the study. It was so low that nobody got infected, which implies that a controlled viral load is pretty safe, safer than what we used to call unsafe sex. And so we need to rebrand; we need to rethink safer sex. We can't just keep on using the same old messages from the '80s and '90s, because they're obviously not working.

We need to add new tools to the arsenal of sexual health. That includes PEP [post-exposure prophylaxis], PrEP and fourth-generation testing, with more frequent testing if you're in a high-risk group. Most people don't know about these new tools and how to use them. It's been very exciting to see in ACT UP a real hunger and awareness, interest in the emerging new science around testing incidence, transmission and epidemiology. If there were more places where those conversations were going on, I think we could have a new generation of activism to really stop the epidemic.

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In terms of the PARTNER study, what should medical providers be saying to their clients?

They should say it's really early days yet, and the sample size is small, and the error bars are large. So far, there have been no transmissions observed. But if we run it out longer and with enough people, eventually there's going to be some.

How much longer, and how many more people?

Well, you can see what Jens Lundgren said about the confidence interval. He was very clear that it's really early days in the study. And the study is not saying it's 100 percent fail-safe; they were very careful about that.

On the other hand, I think it's undoubtedly good news, for that number of people followed for that length of time, that nobody's been infected. That would appear to concord with the 052 study, where there was really zero infections after treatment started. The one infection that happened in the treatment arm was already underway at the enrollment period of the study, which, remember, nobody could believe it when it came out.

What it also shows you, which is unlike the PrEP studies, the adherence to treatment in 052 was incredibly high, or there would have been more infections. There were no infections in the treatment group, except for that one at baseline. In most of the PrEP studies, adherence was all over the map. That's one of the valid issues that people had about the PrEP studies, is that adherence is all over the map. But on the other hand, now that we know PrEP works, adherence might be better, at least, in some groups. Theoretically, you could do tests for adherence with blood levels.

Furthermore, in a few years, when tenofovir [Viread] comes off patent, you'll be able to get PrEP for about 200 bucks a year.

When's that going to happen?

In about 2017. And the long-acting injectables will come around. There will be no adherence for them, unless you just don't get your shot.

So the outlook for chemoprophylaxis is just going to get better. There are going to be more options available for more delivery mechanisms. Even on some of the lists that I've been on, you can see the discussion is shifting from a discussion about condom Nazis or people who are condemning barebacking to much more of a discussion about people saying, "Well, I've started it." "I'm starting it." "I'm thinking of starting it." "Why did my doctor send me to a specialist just to get a prescription?"

People are at least willing to say that they are considering doing it. I think that's a really good sign. People were absolutely desperate for stuff. They were even willing to do stuff that didn't work for a long time, because there was nothing that worked or because there was nothing that they knew worked. And then, as the years went on, some of us asked for higher standards of data. Because some stuff worked for a little bit, but it didn't work for very long. And we wanted it to work longer.

We need to have standards for data and high-quality data in prevention, just like we do in treatment. People shouldn't be still putting crap in our bodies, and people should be able to use any tool that can help them not become HIV infected, whether that means more frequent testing, chemoprophylaxis, barrier methods, legal clean needles or [circumcision].

Let's talk about care and treatment for the person with HIV. Anything exciting that you think is going to be coming down within the next five years?

Well, I think dolutegravir [Tivicay, DTG] is very exciting. It's probably more exciting from the global standpoint, because it will enable us to have a cheaper second-line and maybe even first-line therapy than what we have now because it's going to be cheap to manufacture. It seems to be very potent. It's really the first drug that's come along that's really clearly more potent than efavirenz [Sustiva, Stocrin] and either more potent or equipotent with the protease inhibitors, darunavir [Prezista] and atazanavir [Reyataz]. So we really have an integrase inhibitor that's as good, or more potent than any of our other drugs. And it's a small molecule, once daily, without a booster. It's a huge breakthrough. It also happens to treat raltegravir [Isentress]-resistant [virus].

Are we concerned about resistance?

Anytime you have an antimicrobial drug, there is going to be resistance. The only way to prevent it is to not ever give the drug out at all. So we're going to have resistance to anything.

What's interesting is that, since the advent of HAART [highly active antiretroviral therapy], the incidence of transmitted drug resistance has actually gone down, because most of the people in the '90s that were on partially suppressive therapy, they got resistant to everything they were on. After HAART, most people don't become resistant at all if they're adherent -- or they might become resistant to one thing, and then they switch. So incidence of transmitted drug resistance is under 10%. And we've had HAART for 18 years now. It was higher in '94 than it is now.

I'm not terribly worried about resistance. I'm worried about people not being able to get treatment that they need, because of price, costs or health system barriers.

There are other drugs. But we're at the point where, in HIV therapy, things are pretty good, and getting better. I think where a lot of action is going to be is in trying to figure out how to improve our game and other aspects, like in chemoprophylaxis and vaccines. We're very, very far from having a vaccine.

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